Anorectal disease

Question 1

Compare internal vs. external hemorrhoids based on location

Answer 1

Internal - proximal to **Dentate line (sup hemorrhoidal veins and painless)

External - distal to Dentate line (inf hemorrhoidal vein and painful)

Question 2

What are some typical causes of hemorrhoids?

Answer 2

Increased venous pressure from:

Straining
Constipation
Prolonged sitting
Pregs
Obesity
Low fiber

Question 3

Differentiate between epithelium of internal and external hemorrhoids. Why does this matter?

Answer 3

Internal - COLUMNAR epithelium can deposit mucous on skin and cause ITCHING

External - squamous epithelium w/ pain receptors

Question 4

How will a typical hemorrhoid patient present?

Answer 4

C/o bright* red* rectal bleeding. Streaks on the TP or dripping into the toilet.

May also say they have Perianal itching, Mucoid discharge w/ stool, and pain w/ **EXTERNAL hemm.

Question 5

Prolapse of internal hemorrhoid may result in what?

Answer 5

Leakage of rectal contents.

Patients over-clean and irritate the perineum…. fecal material on denuded skin

Question 6

What results in prolonged contact of fecal material with perianal skin and local irritation? **Not secondary to cleaning

Answer 6

Skin tags from external hemorrhoids (difficult to clean)

Question 7

What are the pearls of a hemorrhoid physical exam?

Answer 7

EXT hemorrhoids may be VISIBLE
INTERNAL may prolapse with VALSALVA

You have to:
Look for Tags, Fissures, Fistulas, Condyloma, Dermatitis
Do a DRE
Do an ANOSCOPIC exam if you are unsure

Question 8

Describe the internal hemorrhoids grading classification.

Answer 8

Graded on degree of PROLAPSE

1. only bleeding
2. Prolapse when poop, back in on own
3. Prolapse when poop, must be pushed back
4. Incarcerated prolapse, cant go back

Question 9

How will a thrombosed hemorrhoid patient present? What needs to happen for this person?

Answer 9

UNRELENTING PAIN due to clot (if external **most common)
Internal can also thrombose

Pt needs SURGICAL evacuation of clot

Question 10

Describe general treatment of hemorrhoids (non pharm)

Answer 10

High FIBER
Increase FLUID
Wet WIPES (hygiene and pain relief)

Question 11

Describe Medical treatment of hemorrhoids.

What if they are Internal and require further tx?

Answer 11

Topical Astringent (Witch hazel/tucks)
Topical Hydrocortisone (cream or foam)
Topical anesthetics (Pramoxine or Dibucaine)
Hydrocortisone suppositories (Prep H)

If further tx needed and internal:

Band ligation
Sclerotherapy
Electrocoagulation

Question 12

When is surgical treatment required for hemorrhoids? Whats the risk?

Answer 12

Only if meds fail or….
Chronic severe bleeding is present

May cause fecal incontinence***

Question 13

Define an anal fissure.

Answer 13

A TEAR in the anoderm DISTAL to the dentate line.

Question 14

Why do people get anal fissures?

Answer 14

Most common cause = Trauma to anal canal during defecation.

Strain, constipated, High INTERNAL sphincter tone

Question 15

An anal fissure can be acute or chronic. How does a chronic fissure develop?

Answer 15

Spasm of the internal sphincter –> impaired healing

Question 16

Where are anal fissures most likely to develop? If they don’t develop here, what should we think about?

Answer 16

Posterior midline 75%. Anterior 25%

If not midline, think:

Crohn, HIV, TB, Syphilis, Carcinoma, Trauma

Question 17

How will an anal fissure patient present?

Answer 17

Acute onset of SEVERE, TEARING pain during defecation… If chronic, LESS PAIN.

Mild HEMATOCHEZIA - BRB on the TP

CONSTIPATION - self induced due to fear

Question 18

What will we find during PE of an anal fissure PT

Answer 18

anal fissure - *small tear in epithelium

Spread buttocks = PAIN

DRE = PAIN *so don’t

Sentinal pile** - skin tag at fissure edge

Question 19

How will we treat an anal fissure?

Answer 19

Acute: 
Sitz bath
Fiber and Fluid
Stool Softeners (ducosate **surfactant)
Topical anesthetic - Lidocaine

Chronic
Topical VASODILATOR - Nifedipine, Nitro, Diltiazem
Botulinum Toxin

Surgical
Fissurectomy
Lateral internal Sphincerotomy

Question 20

Define a perianal abcess

Answer 20

Abscess…. Perianal…..

“Collection of purulent material that arises from GLANDULAR CRYPTS in the anus or rectum”

Question 21

How will a patient with a Perianal Abscess present?

Answer 21

Severe pain ** not assoc w/ defecation (compare fissure)

Fever* and malaise

Question 22

What will we find on PE of a perianal abscess pt?

Answer 22

Erythematous, edematous **Fluctuant skin
W/ surrounding induration

*******ALWAYS DO A DRE. You may not immed see the abscess

Question 23

How do we treat a patient with Perianal Abscess?

Answer 23

Simple - I and D outpatient

Complex - surgical drainage inpatient

Question 24

Name and describe the complication of a Perianal Abscess

Answer 24

FISTULA in ano

Epitheliazed connective passage from anus or rectume to perirectal skin.

CHRONIC purulent drainage, pruritis, pain

**Needs surgical excision

Question 25

Infectious proctitis is typically secondary to what type of infection?

Answer 25

STI

Gonorrhea, Syphilis, Chlamydia, Herpes

Question 26

How will an infectious proctitis patient present?

Answer 26

Anorectal discomfort with Mucus or Bloody discharge
Tenesmus
Constipation

*STI related other symptoms.

Question 27

Describe the associated symptoms of infectious proctitis based on specific STI’s. How do we confirm?

Answer 27

Syphilis = Chancer
Herpes = Vesicles
Gonorrhea = mucopurulent discharge
Chlamydia = slight discharge but **may be asymptomatic

Do a lab test for pathogen

Question 28

What four things do we need to know about Condylomata Acuminata?

Answer 28

1. Anal Warts
2. Itching, bleeding, pain
3. May coalesce and obscure anal opening in immune supp.
4. You need to r/o cancer

Question 29

List 4 facts about carcinoma of the anus

Answer 29

1. Its RARE
2. majority are SQUAMOUS cell
3. High risk in ANORECEPTIVE pts
4. High risk w/ ANAL WARTS

Question 30

How will a patient with Carcinoma of the anus present? What should we do?

Answer 30

Hemorrhoid like symptoms:

Bleeding, pain, local mass

Do a CT or MRI to diagnose and look at extent of spread.